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Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_13 | Pages 12 - 12
17 Jun 2024
Shah K Battle J Hepple S Harries B Winson I Robinson P
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Background

Open subtalar arthrodesis has been associated with a moderate rate of non-union, as high 16.3%, and high rates of infection and nerve injury. Performing this operation arthroscopically serves to limit the disruption to the soft tissue envelope, improve union rates and reduce infection. Our study describes our outcomes and experience of this operation.

Method

Retrospective review of all patients who underwent an arthroscopic subtalar arthrodesis between 2023 and 2008. We excluded patients undergoing concurrent adjacent joint arthrodesis. The primary aim was to report on rates of union. Secondary outcomes included reporting on conversion to open procedure, duration of surgery, infection, and iatrogenic injury to surrounding structures.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_7 | Pages 17 - 17
8 May 2024
Senthi S Miller D Hepple S Harries W Winson I
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Tendoscopy in the treatment of peroneal tendon disorders is becoming an increasingly safe, reliable, and reproducible technique. Peroneal tendoscopy can be used as both an isolated procedure and as an adjacent procedure with other surgical techniques. The aim of our study was to review all peroneal tendoscopy that was undertaken at the AOC, by the senior authors (IGW, SH), and to determine the safety and efficacy of this surgical technique.

Methods

From 2000 to 2017 a manual and electronic database search was undertaken of all procedures by the senior authors. Peroneal tendoscopy cases were identified and then prospectively analysed.

Results

51 patients (23 male, 28 female) were identified from 2004–2017 using a manual and electronic database search. The mean age at time of surgery was 41.5 years (range 16–83) with a mean follow-up time post operatively of 11.8 months (range 9–64 months). The main indications for surgery were lateral and/or postero-lateral ankle pain and lateral ankle swelling. The majority of cases showed unstable peroneal tendon tears that were debrided safely using tendoscopy. Of the 51 patients, 23 required an adjacent foot and ankle operation at the same time, 5 open and 17 arthroscopic (12 ankle, 5 subtalar). Open procedures included 2 first ray osteotomies, 2 open debridements of accessory tissue, one PL to PB transfer. One patient also had an endoscopic FHL transfer. Complication rates to date have been low: 2 superficial wound infections (4%) and one repeat tendoscopy for ongoing pain. A small proportion of patients with ongoing pain were treated with USS guided steroid injections with good results.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_7 | Pages 13 - 13
8 May 2024
Winson D Lawrence O Cazzola D Winson I
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Fifth metatarsal fractures in sport are known to be associated with acceleration and cross cutting movements when running. It is also established that playing surface has an impact on the ground reaction forces through the foot, increasing the strain through the fifth metatarsal. But what impact does boot design have on these forces? Current thought is that boots that utilise a blade stud design resist sideways slipping of the planted foot more than boots with a rounded stud. This study aims to compare ground reaction forces through the fifth metatarsal in 2 two different designs of rugby boot to assess what impact stud design might have. The forces across the foot were measured using Tekscan in-shoe pressure plates in 24 rugby players. Each player was asked to complete an agility course to measure acceleration, cutting and cross-cutting in the two different designs of rugby boot, reproducing true playing conditions. The boots used were the Canterbury Phoenix Club 8 Stud boot and the Canterbury Speed Club Blade boot. The trial was conducted on an 4G artificial pitch at the Cardiff Arms Park rugby ground. Ethical approval was obtained from Bath University and a research grant was provided by British Orthopaedic Foot and Ankle Society. The blade boot had significantly higher contact pressures than the stud boot on the fifth metatarsal in the combined movements (17.909 ± 10.442 N/cm2 Blade Vs 16.888 ± 9.992 N/cm2 Boot; P < .0125; n= 864 steps in each boot group). The blade boot also produced higher pressure during cross-cutting (32.331 ± 13.568 N/cm2 Vs 27.651 ± 15.194 N/cm2 p < 0.007). Pressures were also higher in both acceleration and cutting, although not significantly so. These results will guide clinicians advising athletes in shoe design, especially those predisposed to or rehabilitating from a fifth metatarsal fracture.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_7 | Pages 6 - 6
8 May 2024
Miller D Senthi S Winson I
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Background

Total ankle replacements (TARs) are becoming increasingly more common in the treatment of end stage ankle arthritis. As a consequence, more patients are presenting with the complex situation of the failing TAR. The aim of this study was to present our case series of isolated ankle fusions post failed TAR using a spinal cage construct and anterior plating technique.

Methods

A retrospective review of prospectively collected data was performed for 6 patients that had isolated ankle fusions performed for failed TAR. These were performed by a single surgeon (IW) between March 2012 and October 2014. The procedure was performed using a Spinal Cage construct and grafting in the joint defect and anterior plating. Our primary outcome measure was clinical and radiographic union at 1 year. Union was defined as clinical union and no evidence of radiographic hardware loosening or persistent joint lucent line at 1 year.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_21 | Pages 3 - 3
1 Dec 2017
Touzell A Harries W Winson I Pentlow A
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Introduction

Talus fractures have traditionally been reported as having poor outcomes with rates of avascular necrosis in excess of 80% in some studies. It was noted by the senior author that this was not his experience in a tertiary institution with many patients having good to excellent outcomes and lower rates of avascular necrosis than anticipated despite high-energy trauma. The aim of this paper is to review all talus fractures that have been fixed internally at our institution to determine whether current surgical techniques have improved traditionally poor outcomes. This could result in improved outlook for patients on initial presentation and improved ability to manage the long-term consequences of the multiply-injured patient.

Method

A review of all lower limb trauma cases from 2012–2015 was made. This yielded 28 talus fractures that had been internally fixed at Southmead hospital.

Patients were contacted using telephone and letters. The AAOS Foot and Ankle Outcome Questionnaire, patient satisfaction surveys and analysis of radiographs were made.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_21 | Pages 22 - 22
1 Dec 2017
Robinson P Senthi S Nall A Hepple S Harries W Winson I
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Introduction

Flexor Hallucis Longus (FHL) tendon transfer is a well-recognised salvage operation for irreparable tendon Achilles (TA) ruptures and intractable Achilles tenonopathy. Several case series describes the technique and results of arthroscopic FHL tendon transfers. We present a comparative case series of open and arthroscopic FHL tendon transfers from Southmead Hospital, Bristol, UK.

Methods

For the arthroscopic FHL transfers in most cases the patients were positioned semi prone with a tourniquet. A 2 or 3 posterior portal technique was used and the tendon was secured using an RCI screw. The rehabilitation was similar in both groups with 2 weeks in an equinus backslab followed by gradual dorsiflexion in a boot over the following 6 weeks. Anticoagulation with oral aspirin for 6 weeks was used. A retrospective case note review was performed.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_19 | Pages 19 - 19
1 Nov 2016
Sinclair V O'Leary E Pentlow A Hepple S Harries B Winson I
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Introduction

Arthroscopic ankle fusion is an effective treatment for end stage ankle arthritis. It reliably improves pain but at the expense of ankle motion. Development of adjacent degenerative joint disease in the foot is thought to be a consequence of ankle fusion due to altered biomechanics. However, it has been reported to be present on pre-operative radiographs in many patients. There is very little evidence reporting the long-term outcomes of patients undergoing arthroscopic ankle fusion and particularly those requiring secondary procedures for adjacent joint disease.

Material and methods

We reviewed the operative records of 149 patients who had undergone arthroscopic ankle fusion under the care of two consultant foot and ankle surgeons between 2002 and 2006. We contacted patients by telephone to determine whether they had required further investigation or surgery on the same foot after their index procedure. Secondary outcome measures included a Manchester Oxford Foot Questionnaire (MOQFQ) score and a patient satisfaction score.


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_14 | Pages 15 - 15
1 Dec 2015
Walter R Harries W Hepple S Winson I
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The ZenithTM total ankle replacement (Corin, Cirencester) is a mobile-bearing implant based on the Buechal Pappas design. Key features are the simple fully-jigged instrumentation aiming to improve accuracy and reproducibility of implant positioning, cementless calcium phosphate coated surfaces for improved early osseointegration, and titanium nitride-coated bearing surfaces to resist wear. We present early to mid-term survival data for 155 total ankle replacements implanted by three surgeons in our institute.

Case records of all patients undergoing ZenithTM Total Ankle Replacement by three senior surgeons, including a member of the design team, between 2007 and 2014 were examined. Patients were examined clinically and radiographically annually after the early postoperative period. The primary outcome measure was implant survival. Secondary outcome measures included complication rates, parameters of radiographic alignment, and radiographic evidence of cysts and loosening.

One hundred and fifty-five cases were performed for a mixture of primary pathologies, predominantly primary or posttraumatic arthrosis. Mean follow-up was 50 months. Implant survival was 99.0% at 3 years (n=103), 94.0% at 5 years (n=50), and 93.8% at 7 years (n=16). One patient was revised to arthrodesis for aseptic loosening, one arthrodesis was performed for periprosthetic infection with loosening, and one below-knee amputation was performed for chronic pain. Three cases underwent further surgery to address cysts, and 7 malleolar fractures were reported. Medial gutter pain was experienced by 9% of patients.

Overall, our data show excellent early and mid-term survivorship for the ZenithTM Total Ankle Replacement. Simple fully-jigged instrumentation allows accurate and reproducible implant alignment.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_2 | Pages 4 - 4
1 Jan 2014
Kakwani R Higgs A Hepple S Harries W Winson I
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Aim:

Ankle sprains are one of the most common sports injuries. Around 10–20 % of the acute ankle sprains may lead to the sequelae of chronic ankle instability. Around 15–35% of the patients have residual pain following successful lateral ligament reconstruction. One of the reasons suggested for the persistent symptoms following lateral ligament reconstruction has been the presence of intra-articular pathology.

Methods and materials:

We performed ankle arthroscopy on all patients undergoing the modified Brostrom repair and compared patients with associated intra-articular pathology to those without any intra-articular pathology.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_2 | Pages 29 - 29
1 Jan 2014
Jagodzinski N Hughes A Davis N Butler M Winson I Parsons S
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Introduction:

Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe a purely arthroscopic technique for excising talocalcaneal coalitions. We present a retrospective two-surgeon case series of the first eight patients (nine feet).

Methods:

Subtalar arthroscopy is performed from two standard sinus tarsi portals with the patient in a saggy lateral position. Coalitions are resected with a barrel burr after soft tissue clearance with arthroscopic shavers. Early postoperative mobilisation and non-steroidal anti-inflammatory drugs prevent recurrence of coalition. Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 to 5.5 years.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_18 | Pages 17 - 17
1 Apr 2013
Jagodzinski N Hughes A Davis N Butler M Winson I Parsons S
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Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe an entirely arthroscopic technique for excising talocalcaneal coalitions and present a retrospective two-surgeon case series of the first eight patients (nine feet).

Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 year to 5.5 years.

Subtalar movements were improved in all feet. Deformity was not always fully corrected but pain and SAFAS scores improved in all patients bar one. They all had a rapid return to good function apart from this same patient who required subsequent fusions. The posterior tibial nerve was damaged in one patient.

Minimal destruction of bone and soft tissues allows early mobilization and minimizes pain. We acknowledge the risk of neurological damage from any operative technique. Patient selection and preoperative planning are crucial. This series from two independent surgeons supports the feasibility and effectiveness of this technique.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 63 - 63
1 Jan 2013
Thyagarajan D James S Winson I Robinson D Kelly A
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Osteochondral lesions (OCL) of the talus occur in 38% of the patients with supination external rotation type IV ankle fractures and 6 % of ankle sprains. Osteoarthritis is reported subsequently in 8–48% of the ankles. Several marrow stimulation methods have been used to treat the symptomatic lesion, including arthroscopic debridement and micro fracture. Encouraging midterm results have been reported, but longterm outcome is unknown in relation to more invasive treatments such as transfer of autologous osteoarticular tissue from the knee or talus (OATS), autologous chondrocyte implantation (ACI), frozen and fresh allograft transplantation.

Aim

The aim of our study was to review our long term results of arthroscopic treatment of osteochondral lesions of the talus.

Materials and methods

65 patients underwent arthroscopic treatment of the OCL between 1993 and 2000. There were 46(71%) men and 19(29%) women. The mean age at surgery was 34.2 years. The right side was affected in 43 patients and the left side in 22 patients.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 70 - 70
1 Sep 2012
McKenzie J Barton T Linz F Barnet S Winson I
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The relationship between hindfoot and forefoot kinematics is an important factor in the planning of ankle arthrodesis and ankle arthroplasty surgery. As more severe ankle deformities are corrected, improved techniques are required to assess and plan hindfoot to forefoot balancing.

Gait analysis has previously been reported in patients with ankle arthritis without deformity. This group of patients have reduced intersegment motion in all measured angles. We have looked at a small group of patients with hindfoot deformity and ankle arthritis awaiting fusion or replacement.

Using the Oxford Foot Model we have assessed lower limb kinematics with a focus on hindfoot to forefoot relationships. The results of our pilot study are in variance to previous studies in that we have shown that in the presence of hindfoot/ankle deformity, the forefoot range of motion increases. We feel that these data may impact on surgical planning.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 62 - 62
1 Sep 2012
Winson I Morssinkhof M Wang O James L van der Heide H
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Background

Many scoring systems exist that assess ankle function, none of them are validated for use in a group of higher demand patients. This group of patients there have potential problems with ceiling effects, not being able to detect change or that a sports-subscale is not included. This study was to create a validated self-administered scoring system for ankle injuries in athletes by studying existing scoring systems and key-informant interviews.

Methods

The Sports Athlete Foot and Ankle Score (SAFAS) was developed from interviews with athletes as well as expert-opinions. Initially 26 patients were interviewed before creating the scoring system, this was modified from the Foot and Ankle Outcome Score, this had been partially validated previously and the subjects regarded the content as relevant but incomplete. Secondly, SAFAS the content was validated in a group of 25 patients with a range of injuries and 14 athletes without ankle injury. It is a self-administered region specific sports foot and ankle score that containing four subscales assessing the levels of symptoms, pain, daily living and sports.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 59 - 59
1 Sep 2012
Lintz F Barton T Harries W Hepple S Millett M Winson I
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Background

Traditional measurements of hindfoot alignment are based on the tibio-calcaneal angle and do not take the forefoot into account. We have developed an algorithm based on standard radiographs to calculate calcaneal offset using Ground Reaction Force (GRF).

Hypothesis

The GRF algorithm measures hindfoot alignment without using the tibial axis


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXII | Pages 20 - 20
1 May 2012
Winson I
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The diagnosis of Osteochondral Chondral Lesion of the talar dome is ever more regularly made. Though algorithms of management have emerged by recognising the position, size and the most reliable treatment options, the problem of the failed or relapsed case has only been considered in limited publications.

When considering the failed case a variety of possibilities have to be considered.

The characteristics of the patient have to be considered. The nature of the original presentation and the history of the present as opposed to the past compliant are worth noting. Patients who have no history of trauma do seem to have a different natural history and response to treatment. The young and the old may well respond differently.

Factors preventing recovery from surgery such as ongoing instability of the ankle or hindfoot deformity creating on going abnormal pressures on the joint surface should be looked for.

The possibility that the surgery undertreated or missed the full nature of the lesion has to be considered. The possibility of an untreated further pathology should be reviewed.

The severity of the original lesion and it's likely response to treatment should be considered. Larger cystic lesions would be more likely to have a poorer outcome. Ultimately if there are persistent symptoms and evidence of ongoing unresolved pathology on the joint surface alternative techniques to resurface the joint should be considered.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_II | Pages 59 - 59
1 Feb 2012
Sheridan B Robinson D Hubble M Winson I
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Hind and mid foot arthritis is often noted in patients who have previously had an ankle arthrodesis. It has been suggested that this arthritis may be precipitated or exacerbated as a direct result of the ankle fusion. The aim of this study was to investigate the degree and pattern of pre-existing ipsilateral foot arthritis in patients who have subsequently undergone ankle arthrodesis.

A retrospective review of the most recent pre-operative radiographs of 70 patients who underwent 71 arthrodeses between 1993-2003 was performed. Patients with rheumatoid disease were excluded. The immediate pre-operative AP and lateral ankle radiographs were assessed and the presence and severity of osteoarthritis for the sub-talar, talo-navicular, naviculo-cuneiform and calcaneo-cuboid joints was recorded using the Kellgren and Lawrence grading score. This was performed simultaneously by two reviewers and a consensus obtained. A total score out of 16 was given for each radiograph.

68 (96%) of the radiographs reviewed showed evidence of pre-existing hind or mid foot arthritis prior to ankle fusion. The sub-talar joint was the most commonly and severely affected. The median total arthritis score for each radiograph was 5. There was no association between age or causative pathology and the degree of arthritis.

This study has demonstrated that hind and mid foot arthritis is very common in patients with co-existent ankle arthritis prior to ankle fusion. This has previously been assumed to have developed as a result of the surgery but is, in fact, present at the time of the operation and this needs to be taken into consideration when evaluating the results of ankle arthrodesis


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_II | Pages 54 - 54
1 Feb 2012
Budnar V Hammett R Livingstone J Harries W Hepple S Winson I
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Simultaneous arthrodesis of the ankle and subtalar joints is an established treatment option for combined ankle and subtalar arthritis or complex hindfoot deformities. The use of a curved intra medullary nail has potential advantages in terms of stability, hindfoot alignment and avoidance of the lateral neurovascular bundle.

We devised a comparative description of the results of hindfoot fusion using a curved locking nail before and after the introduction of anatomically specific modifications to the device through a retrospective review of notes and radiographs of patients undergoing simultaneous ankle and subtalar fusion by retrograde intramedullary nailing using an ACE¯ (Humeral Nail. Patients undergoing the same procedure using the Tibiotalocalcaneal [TTC] Nail System [DePuy] were recruited and studied prospectively. The outcome was assessed by a combination of notes review, clinical examination and telephone questionnaire.

Between 1996 and 2004, 71 arthrodeses in 67 patients have been performed. The average follow up is 27 months [3-73] and mean age 58 years. Fifty-two arthrodeses utilised the ACE humeral nail and nineteen used the newer TTC nail. Both nailing systems are locked proximally and distally and provide a short radius laterally directed distal curve. Mean time to union is 4.3 months [3-10]. Average AOFAS hindfoot score post-operatively is 65, with a mean improvement of 40 points from the pre-operative score in the TTC nail group. Post-operative complications included deep infection, amputation and a non-union rate of 10% overall. In the humeral nail group, four symptomatic stress reactions [8%] and three fractures of the tibia [6%] occurred at the tip of the nail. No stress-riser effect has to date been seen in the TTC nail group. Prominent metalwork removal has also been significantly reduced in the TTC nail group.

Our results show hindfoot fusion using a curved intramedullary nail to be an effective technique in complex cases of hindfoot arthritis and deformity. Anatomically specific alterations to the nail have resulted in a significant reduction in certain complications. Alternate proximal locking options in the TTC nail have reduced prominent metalwork and, more significantly, the incidence of stress reactions and fractures appears to have been eliminated.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_I | Pages 241 - 242
1 Mar 2010
Parker S Hepple S Winson I
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Introduction: Non-union following hindfoot arthrodesis remains a significant risk in foot and ankle surgery. In the reported series of revision hindfoot arthrodeses non-union rates range from 9 to 25% with approximately half these patients going on to a transtibial amputation. Bone morphogenic proteins (BMP) are a group of naturally occurring proteins with strong osteoinductive properties, which have shown promise in the treatment of fracture non-unions and primary hindfoot arthrodesis surgery. This article reports our experiences with rhBMP-7 as an adjunct to revision arthrodesis surgery in this high-risk subset of patients.

Methods: Eight patients with at least one previous non-union and two or more risk factors for non-union and one patient on steroids with a failed total ankle replacement were prospectively recruited to the study. A revision arthrodesis procedure with internal fixation was performed according to the senior author’s revision protocol with the addition of 3.5mg rhBMP-7 combined with 40mls of bone marrow aspirate. Bone graft was used only if there was structural bone loss. Outcome was assessed clinically and radiologically.

Results: Follow-up ranges from 3 to 22 months (average 13 months). Clinically 8 of the 9 patients had a pain free, stable arthrodesis. Seven patients were satisfied with their functional improvement and pain relief. Radiologically two patients have united, six patients have partial unions with ongoing progression towards union and one patient has a painless non-union. There was one wound infection and one malunion. No complications related to rhBMP-7 were experienced.

Conclusion: Revision arthrodesis with adjuvant rhBMP-7 has led to limb salvage in this group of high-risk patients. However, rhBMP-7 is not a panacea for achieving union and does not replace meticulous surgical planning and technique. Achieving bony union in this subset of patients remains a high risk and protracted process. No concerns about the short-term safety of rhBMP-7 were raised.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_I | Pages 100 - 100
1 Mar 2009
Whitehouse M Lankester B Winson I Hepple S
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Introduction: Fresh autogenous cancellous bone graft is the material of choice in reconstruction and fusion procedures in foot and ankle surgery. There are many potential donor sites for graft harvest, all with recognised minor and major complications. The proximal tibia is one such potential site, and is particularly suited to foot and ankle surgery being within the operative field and under tourniquet control.

Purpose: To assess pain, morbidity and ability to weight bear in a large group of patients undergoing foot and ankle surgery utilising cancellous bone graft from the proximal tibia.

Method: A retrospective audit was undertaken of 148 procedures performed over a period of five years. Minimum follow-up was 3 months. Data were obtained from operation notes and patient interview.

Results: Most patients had no pain (78%) or very mild pain (20%) at the site of graft harvest immediately following surgery. At review, 96% had no pain; 4% had very mild pain with certain activities such as kneeling. There were no major complications. 4 patients (2.7%) had persisting areas of parasthaesia at review, but none were troubled by it. One patient had a superficial wound problem that resolved. The ability to bear weight was dictated by the primary procedure. Usually this was from 2–3 weeks. There were no complications related to early weight bearing in this series.

Conclusion: The proximal tibia is a suitable and safe site for bone graft harvest for foot and ankle surgery. There is no need for additional restriction in weight bearing following this procedure.